Voluntary Medical Male Circumcision — Southern and Eastern Africa, 2010–2012

Sub-Saharan Africa bears the greatest global burden of human immunodeficiency virus (HIV) infection; 70% (25.0 million) of all persons living with HIV reside in this region. Voluntary medical male circumcision (VMMC) has been shown to reduce the risk for heterosexually acquired HIV among men by approximately 60% in three randomized controlled trials. Further studies found that the protection from HIV acquisition conferred by VMMC was sustained for 6 years following surgery. In 2007, the World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that 14 countries with generalized HIV epidemics (i.e., where >1% of the population is HIV-positive) and low male circumcision prevalence prioritize scale-up of VMMC for HIV prevention. On December 1, 2011 (World AIDS Day), funding through the President's Emergency Plan for AIDS Relief (PEPFAR) was announced to support >4.7 million VMMCs over the next 2 years. This report presents the results of VMMC scale-up in nine countries where national ministries of health and CDC are implementing VMMC services for HIV prevention: Botswana, Kenya, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, and Zambia. During October 2009-September 2012, a total of 1,924,792 VMMCs were performed in 14 countries using PEPFAR funding provided through U.S. government agencies; of this total, 1,020,424 were conducted at approximately 1,600 CDC-supported VMMC sites: 137,096 VMMCs in 2010, 347,724 in 2011, and 535,604 in 2012. Continued program monitoring and quality assurance activities are required to ensure that CDC-supported country programs meet World AIDS Day targets for VMMC.

clients provided informed consent, or assent with permission from a parent or guardian for those aged <18 years. If clinicians determine that a client aged <15 years understands the information provided and is able to cooperate with VMMC under local anesthesia, then surgery can be performed, as long as assent and permission is provided. Data from approximately 1,600 CDCsupported sites were pooled by CDC country offices from local VMMC implementing partners and used to generate summary statistics. Multicountry analyses were conducted to document VMMC progress by examination of data for VMMCs performed, client age, HIV testing and counseling (HTC) acceptance and results, postoperative reviews, and postoperative moderate and severe adverse events (AEs) from 2010-2012. Moderate and severe AEs (e.g., excessive bleeding, infection, swelling, or wound disruption) were classified by type and severity according to PEPFAR's indicator guidance. † † Some countries use AE definitions that vary slightly from country to country. Annual data were not available from all countries (Table 1).
During 2010-2012, approximately 1,020,424 males were circumcised at CDC-supported sites in the nine countries. The total number of VMMCs has increased each year: 137,096 VMMCs performed in 2010 (seven countries), 347,724 in 2011 (eight countries), and 535,604 in 2012 (nine countries). CDC-supported VMMC programs in Kenya and Uganda performed the most VMMCs during these years: 386,752 and 205,812, respectively (Table 1).
All VMMC clients are advised to return to a health facility for postoperative assessment. Of the countries reporting data on postoperative visits of VMMC clients (n = 614,478), a total of 359,881 clients (58.6%) returned for assessment at the circumcising site within 14 days of surgery. Postoperative follow-up rates have been inconsistent at 75.7% (three countries), 50.0% (five countries), and 64.8% (seven countries) for 2010, 2011, and 2012, respectively. Among all clients returning for postoperative follow-up review within 14 days, the overall postoperative moderate or severe AE rate was low (0.8%), and   (Table 3). To reach 80% coverage and the World AIDS Day VMMC goals, country programs have implemented various efficiency models to expedite scale-up. Each of the nine countries included in this analysis has introduced components of WHO's model for optimizing the volume and efficiency of male circumcision services (i.e., MOVE) (10), including the use of standardized VMMC surgical techniques (nine countries), electrocautery (four countries), use of nonphysicians and lower cadres of health-care providers (nine countries). Most countries rely on nonphysicians (i.e., nurses and clinical officers) to perform VMMC surgery. VMMC country programs are also  implementing standardized training programs for all cadres of VMMC providers; targeted, client-specific campaigns to increase demand for VMMC; and routine, site-level quality assurance assessments. Many countries are moving toward a mixed-service delivery model that combines fixed VMMC sites (e.g., permanent sites within existing health-care facilities, such as hospitals and health centers) with mobile and outreach sites (e.g., use of tents, prefabricated structures, and other temporary locations for VMMC service delivery). All sites offering VMMC must provide the "minimum package" of complementary services specified by WHO, including information about the risks and benefits of the procedure, HTC, screening, and treatment of sexually transmitted infections; preoperative and postoperative counseling; and promotion and provision of condoms (10).

TABLE 2. Voluntary medical male circumcision (VMMC) progress, HIV testing and counseling (HTC) acceptance, human immunodeficiency virus (HIV) prevalence among VMMC clients, postoperative follow-up reviews among VMMC clients, and postoperative moderate or severe VMMC adverse event (AE) rates, by country and year, 2010-2012
The findings in this report are subject to at least four limitations. First, several countries did not begin scaling up VMMC until 2010 or 2011, which is partially responsible for missing data. Second, because of differing numbers of countries included in the analyses of different variables across years, trends found might not be representative of all VMMC clients. Third, ministry of health-approved client-level data collection tools are not identical across countries, which contributed to difficulties in data aggregation across countries, including the lower age limit for VMMC clients. Finally, some national ministries of health have similar but not identical definitions for classifying type, severity, and clinical signs for VMMC AEs. Although PEPFAR guidance for AE reporting is used in all of PEPFAR's VMMC programs, discrepant diagnoses and management might result in differences in reporting.
Quality assurance processes should monitor routine reporting of additional VMMC indicators to ensure data availability and to improve data quality. CDC's external quality assurance activities provide an opportunity to work with ministry of health officials and VMMC implementers to assess and improve data collection and reporting practices. Improved data collection and reporting practices will help CDC-supported country programs meet the World AIDS Day targets for VMMC and achieve an AIDS-free generation.